Methods and apparatus for natural orifice vaginal hysterectomy

Abstract

A transuterine cannula through which an endoscope can be advanced into the peritoneal space to provide visualization of tissue cutting in the peritoneal space pursuant to a vaginal hysterectomy.

1. An assembly for transuterine visualization of a transvaginal hysterectomy, comprising:
 an elongated transuterine cannula configured for advancement through the vagina and uterus to a distal wall of the uterus; 
 at least one sealing device engaged with the transuterine cannula to engage the cannula with the distal wall; 
 at least one penetrating element associated with the transuterine cannula to fenestrate the distal wall to form an opening therein; 
 at least one endoscope advanceable through the cannula and opening in the distal wall of the uterus into a peritoneal space to provide visualization of anatomical structure in the peritoneal space; and 
 a vaginal guide shaped and sized for being closely received in a vagina of a patient, the guide being formed with a hole sized to closely receive the transuterine cannula therethrough, in slidable support, the guide further including one or more bands attachable with the patient's skin to hold the guide in place at the vaginal opening, the guide being made of a soft elastomer, the guide stabilizing the vaginal orifice during hysterectomy while providing access portals and preventing injury that might otherwise occur due to repeated insertion and manipulation of instruments into the patient, the guide also providing a resting point and fulcrum for the transuterine cannula. 
 
     
     
       2. The assembly of  claim 1 , further comprising a veress cannula slidably engageable with a lumen of the endoscope. 
     
     
       3. The assembly of  claim 1 , further comprising a dissecting device for cutting the anatomical structure in the peritoneal space for which the endoscope provides visualization. 
     
     
       4. The assembly of  claim 1 , wherein one or more of the transuterine cannula and endoscope can articulate while in a patient. 
     
     
       5. The assembly of  claim 1 , comprising a vacuum shroud surrounding a distal end of the endoscope and communicating with a source of vacuum to attract the distal wall of the uterus toward the endoscope to facilitate fenestration of the distal wall. 
     
     
       6. The assembly of  claim 1 , comprising an obturator disposable in the transuterine cannula to facilitate advancing the transuterine cannula to the distal wall of the uterus. 
     
     
       7. The assembly of  claim 6 , wherein the obturator has a frusto-conical distal segment terminating in a rounded distal tip, and at least the distal tip bears a bipolar electrode array for fenestrating the distal wall of the uterus. 
     
     
       8. The assembly of  claim 1 , wherein the transuterine cannula is formed with a distal neck and a shoulder proximal to the neck and adjoined thereto, the shoulder being wider than the neck for abutting an inner surface of the distal wall of the uterus with the neck disposed in the opening thereof. 
     
     
       9. The assembly of  claim 1 , comprising a uterine stabilizing balloon surrounding a portion of the transuterine cannula and having an inflatable configuration, wherein the stabilization balloon substantially fills the uterus to facilitate manipulation of the uterus, and a deflated configuration, wherein the stabilization balloon is configured to facilitate advancing the transuterine cannula into the uterus. 
     
     
       10. The assembly of  claim 1 , wherein the transuterine cannula defines an outer surface and includes at least one working channel external to the outer surface. 
     
     
       11. The assembly of  claim 1 , the vaginal positioning guide bearing at least one tissue dissector for fenestrating the vagina. 
     
     
       12. The assembly of  claim 11 , wherein the vaginal positioning guide includes a balloon inflatable to substantially fill the vagina to anchor the guide in the vagina when the transuterine cannula extends therethrough into the uterus. 
     
     
       13. The assembly of  claim 1 , wherein the penetrating element is established by a distal tip of the transuterine cannula. 
     
     
       14. The assembly of  claim 1 , wherein the penetrating element is established by a cutting device advanceable through the transuterine cannula. 
     
     
       15. The assembly of  claim 1 , wherein the transuterine cannula is secured to the distal wall of the uterus using a gas seal. 
     
     
       16. The assembly of  claim 15 , wherein the transuterine cannula is secured to the distal wall of the uterus using a pair of gas sealing devices. 
     
     
       17. The assembly of  claim 16 , wherein the gas sealing devices are inflatable balloons. 
     
     
       18. The assembly of  claim 1 , wherein at least the cannula can articulate to facilitate antero- and retro-deflexion to facilitate manipulation of the uterus. 
     
     
       19. The assembly of  claim 1 , further comprising a multiperforated veress shunt cannula slidably engageable with a lumen of the endoscope to establish a pathway for fluid communication from the uterine space of a patient to the abdominal cavity of the patient. 
     
     
       20. A method for conducting a hysterectomy on a patient, comprising:
 insufflating the abdominal cavity; 
 advancing a transuterine cannula into the vagina of the patient, through the cervix and into the uterus; 
 securing the transuterine cannula to the distal wall of the uterus; 
 fenestrating the distal wall of the uterus; 
 advancing an endoscope through the transuterine cannula into the abdominal cavity of the patient; 
 viewing at least portions of the uterus with attached anatomical structures using the endoscope; and 
 removing at least the uterus using at least one instrument placed through the transuterine cannula and/or a working lumen of the endoscope and/or delivered transvaginally. 
 
     
     
       21. The method of  claim 20 , wherein the transuterine cannula is advanced against the distal wall with an obturator contained in the transuterine cannula. 
     
     
       22. The method of  claim 20 , wherein the transuterine cannula is secured to the distal wall using a gas seal. 
     
     
       23. The method of  claim 20 , wherein the transuterine cannula is secured to the distal wall using a pair of gas sealing devices. 
     
     
       24. The method of  claim 23 , wherein the gas sealing devices are inflatable balloons. 
     
     
       25. The method of  claim 20 , wherein the distal wall is transversed using a penetrating element at the distal portion of the transuterine cannula. 
     
     
       26. The method of  claim 20 , comprising introducing a disinfectant into the uterus prior to fenestrating the distal wall.